Shawnee Gardens Healthcare & Rehab Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to the residents of the facility appropriately to prevent the potential for food borne bacteria in one of the kitchens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by failing to ensure the lid of the dumpster was kept closed and failing to ensure the trash bags filled with dietary and nursing trash were kept in an enclosure.

Inspectors wroteBased on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention and Control Program (IPCP), was certified and had completed the specialized training in infection prevention and control

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure a safe, clean, home-like environment in the facility extended recovery unit (ERU) lounge area.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure an environment free from accident hazards when staff failed to secure disinfectant chemicals in a locked area and out of the reach of the 10 cognitively impaired, independently mobile residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete comprehensive Minimum Data Set Assessment (MDS) for two Residents (R)67, regarding discharge and R10, regarding nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for two residents: Resident (R)118, regarding discharge location, and R10, regarding the use of continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary activities of daily living (ADL) services for Resident (R)8, who did not receive adequate assistance with personal hygiene.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests and well-being of Resident (R)11 and R67.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate wheelchair positioning for Resident (R)11.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure Resident (R) 10's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask and oxygen tubing was stored in a sanitary manner to prevent contamination and respiratory infections.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to complete and document a post hemodialysis (a procedure where impurities or wastes are removed from the blood) assessment for Resident (R) 10.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure collaboration with the hospice provider for Resident (R) 2.

Inspectors wroteBased on record reviews and interviews, the facility failed to post the required staffing information when the posted nurse staffing sheet did not list the actual staff hours worked as required.

Inspectors wroteThe facility identified a census of 116 residents. The sample included three residents, with one resident reviewed for abuse. Based on observation, record review, and interviews, the facility failed to report an allegation of abuse from Resident (R) 1 towards R2 to the State Agency (SA).

Inspectors wroteThe facility identified a census of 114 residents. The sample included eight residents, with seven residents reviewed for misappropriation of medications. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1, R2, R3, R4, R5, R6, and R7 remained free from misappropriation of medications. This deficient practice had the risk of missed medications and further misappropriation of medications for the affected residents.

Inspectors wroteThe facility identified a census of 116. The sample included five residents, with one resident reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 was able to exercise her right to receive visitors of their choosing at the time of R1's choice. This deficient practice affected R1's psychosocial well-being and placed R1 at risk for impaired resident rights and social isolation.

Inspectors wroteThe facility identified a census of 116 residents. The sample included five residents. Based on record review and interviews, the facility failed to obtain a physician-ordered urinalysis (UA- lab analysis of urine) and other laboratory tests ordered on 06/03/25. The facility further failed to notify the physician related to the delay in obtaining the ordered UA and laboratory tests for Resident (R) 2. R2 had fallen on 06/05/25 and 06/06/25, and R2 had a change in condition on 06/07/25. [...]

Inspectors wroteThe facility identified a census of 117 residents. The sample included eight residents, with one resident reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to prevent an episode of resident-to-resident sexual abuse for cognitively impaired Resident (R) 2. On 02/08/25, facility staff witnessed R1 groping R2's nipples, breast, and buttocks while both were seated at the dinner table on the locked unit for cognitively impaired residents. R2 voiced she did not consent to R1 touching her. This placed R2 in immediate jeopardy and at risk for ongoing and/or unidentified abuse and feelings of fear for R2, based on reasonable person concept. Findings Included: [...]

Inspectors wroteThe facility identified a census of 117 residents, with eight residents sampled, including two residents reviewed for abuse. Based on observation, record review, and interviews, the facility failed to implement effective preventative interventions related to Resident (R)1's sexual behaviors to protect the female residents in the facility including R2 (See F600). This failure placed 19 female residents at risk. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of sexual behaviors related to psychiatric illness. [...]

Inspectors wroteThe facility identified a census of 117 residents. The sample included eight residents with two reviewed for behavioral services. Based on observation, record review, and interviews, the facility to implement effective behavioral monitoring and interventions related to Resident (R) 1's ongoing sexual behaviors toward female residents. This deficient practice placed R1 at risk for continued behavioral episodes and unmet care needs. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of sexual behaviors related to psychiatric illness. [...]

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This deficient practice placed all 115 residents residing in the facility at risk for inadequate care. Findings Included: - An inspection of the Facility Assessment dated 09/10/24 provided by the facility revealed the following: The assessment did not identify the facility's resident capacity. The assessment did not identify the means of input gathered from the residents and their representatives when formulating the assessment data. The assessment did not identify the specific staffing needs of each unit based on the type of resident population within the unit. [...]

Inspectors wroteThe facility identified a census of 115 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 115 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 115 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required infection control training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 17 and R41's dignity was maintained while being aided with meals. The facility failed to ensure staff maintained R92's dignity during an incontinent accident. The facility failed to ensure staff maintained R35's dignity while personal care was provided. The facility failed to ensure staff treated R108 in the Memory Unit with respect while assistance was provided during mealtime. The facility failed to ensure staff maintained R35's dignity when staff stated that R35 was a Feeder. This deficient practice placed these residents at risk of decreased self-esteem and decreased self-worth.

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents. Based on observations, interviews, and record reviews, the facility failed to accommodate dietary preferences. This deficient practice placed the residents at risk for impaired nutrition and decreased psycho-social well-being. Findings Included- - On 09/16/24 at 09:01 AM the breakfast cart arrived on the unit of the Memory Care Unit. Resident (R)75 stated multiple times that she would like pancakes for breakfast. R75 was told by staff that pancakes were not available and that she would have to eat what was served to her. R75 was provided her meal. After she ate what was on her plate R75 requested toast. She was told by staff that toast was not available and given a bowl of Cheerios cereal. R75 complained she was not given an option for her meal or side items. [...]

Inspectors wroteThe facility identified a census of 115 residents. The facility identified eleven residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. The facility failed to sanitize shared equipment between use. The facility failed to ensure staff performed adequate hand hygiene, ensure trash was stored and contained properly, and that spills or leakage was cleaned under dining room sinks. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified at a census of 115 residents. The sample included 26 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure Resident (R)37's call light was within his reach. This deficient practice left R37 vulnerable for unmet care needs due to the inability to call for staff assistance.

Inspectors wroteThe facility reported a census of 115 residents. The sample included 26 with 26 residents reviewed for care plan revisions. Based on observations, interviews, and record review, the facility failed to revise Resident (R)106's Care Plan to reflect his current toileting needs after discontinuation of his Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). This deficient practice placed R106 at risk for impaired care due to uncommunicated care needs. Findings Included: - R106's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of intracranial hemorrhage (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by rupture of an artery to the brain), aphasia (condition with disordered or absent language function), chronic kidney disease, and agitation. [...]

Inspectors wroteThe facility reported a census of 115 residents. The sample included 26 residents with eight reviewed for activities of daily living (ADLs). Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 99 received supportive care and services to promote and maintain her quality of life when the facility did not implement tools and/or strategies to allow R99 to communicate her wants, needs, or feelings. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: [...]

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents with eight residents sampled for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure staff provided ADL assistance for Resident (R) 92 who was dependent on staff for ADLs. The facility also failed to ensure staff provided assistance for toileting and eating for R68 and R37. This placed these residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents with three sample residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's pressure-reducing interventions were implemented correctly when their low air-loss mattress pump was set at an inappropriate weight for the resident. This deficient practice placed R2 at risk for complications related to skin breakdown and pressure ulcers.

Inspectors wroteThe facility reported a census of 115 residents. The sample included 26 residents with five reviewed for accidents. Based on record review, interviews, and observations, the facility failed to implement the fall intervention of anti-rollback (device to prevent the wheelchair from rolling backward) devices per R41's care plan. The facility additionally failed to ensure a safe environment free from accident hazards when R36's bed was left in a high position. This placed the residents at risk for preventable accidents and injuries. Findings Included: - R41's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of dysphagia (difficulty swallowing), aphasia (difficulty speaking), hemiplegia (paralysis of one side of the body), and epilepsy (brain disorder characterized by repeated seizures). [...]

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently communicate Resident (R) 37's medical condition with the dialysis center. This deficient practice placed R37 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R)99 to promote the resident's highest practicable level of well-being. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: [...]

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents with two medication rooms and four medication carts. Based on observation, record review, and interviews, the facility failed to ensure controlled substances were accounted for and reconciled between shifts. This placed the residents at risk for misappropriation and/or diversion of controlled substances.

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents with five sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported a missing dosage and location of the application for Resident (R) 92's physician-ordered diclofenac (a topical medication used to treat pain and swelling). The facility further failed to ensure the CP recommendations for R35 were submitted to the physician for review. This placed the residents at risk for unnecessary medication side effects.

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents with five sample residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 92's physician ordered diclofenac (a topical medication used to treat pain and swelling) had an indicated dosage or an indicated location to apply the medication. This placed R92 at risk of unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents with three residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration regarding Resident (R) 20 and R5's care between the nursing home and the hospice 24 hours a day, seven days a week including documentation of a description of the services, medication, and equipment provided to these residents by hospice. This deficient practice created a risk of missed opportunities for services and delayed physical, mental, and psychosocial needs for these residents.

Inspectors wroteThe facility identified a census of 115 residents. The sample included 26 residents with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility failed to offer and/or obtain an informed declination for Resident (R) 35 and R75's Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial lung infections). This placed the residents at increased risk for complications related to pneumonia (a type of bacterial infection).

Inspectors wroteThe facility reported a census of 115 residents. The sample included 26 residents. Based on record review and interviews, the facility failed to post the daily staffing with census and maintain 18 months of daily posted staffing hours as required. Findings Included: - On 09/16/24 at 07:05 AM an inspection of the main lobby revealed the daily posted staffing sheet displayed next to the reception desk. The staffing sheet was dated 09/13/24 and lacked a census. On 09/17/24 at 07:10 AM an inspection of the displayed daily posted staffing revealed the correct date but lacked a census of the residents. A review of the facility's Daily Posted Staffing from 04/01/23 to 09/16/24 revealed multiple missing daily posted staffing records from 07/12/23 through 12/01/23. [...]

Inspectors wroteThe facility identified a census of 120 residents. The sample included three residents reviewed for falls. Based on record review and interviews, the facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for Resident (R) 1, who was cognitively impaired. The facility further failed to ensure R1 received post-fall care including neurological evaluations and nursing assessments following an unwitnessed fall that resulted in obvious head trauma on 04/27/24 at 03:28 AM. R1 was later sent out to the hospital on [DATE] at 08:45 AM where he was found to have nasal bone fractures and multiple rib fractures. This also placed R1 at risk for increased pain and other complications.

Inspectors wroteThe facility identified a census of 110 residents The sample included three residents reviewed for accidents. Based on record review, interview, and observation, the facility failed to ensure staff possessed the appropriate knowledge, skills, and training to provide resident care in a safe manner when uncertified Nurse Aide Student (NAS) M transferred Resident (R)1 without a facility staff member or her nursing instructor present. NAS M could not complete the transfer with R1, which resulted in an assisted fall and R1 subsequently diagnosed with a left distal (away from the farthest point of origin or attachment) femur (thigh bone) fracture.

Inspectors wroteThe facility identified a census of 114 residents. The sample included five residents with three residents reviewed for notification of changes. Based on observations, record review, and interviews, the facility failed to provide written notification, including the reason for the change, to Resident (R) 1 and her representative before she moved rooms. This deficient practice had the risk for miscommunication between R1/her representative and the facility and placed R1 at risk for decreased psychosocial well-being related to moving rooms without notice.

Inspectors wroteThe facility identified a census of 106 residents and one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage, preparation, and handling. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 01/18/23 at 07:10AM an initial walkthrough of facility's kitchen was completed. A review of the kitchen's two hand washing sinks revealed the paper towel dispensers were empty with no clean hand drying option available. Next to the sink were several used yellow cloth towels lying on a table. An inspection of the kitchen's microwave revealed old food stains and residue splattered on the inside of the microwave. [...]

Inspectors wroteThe facility identified four medication rooms. The facility failed to maintain refrigerator temperature logs in two of the four medication rooms used for medication and biological storage. This deficient practice placed the residents at risk ineffective medication and related side effects. Findings Include: - On 01/18/23 at 10:20AM an inspection of the facility's first floor medication room (100-121 hallway) revealed that the temperature log on the medication refrigerator were from August 2022. Licensed Nurse (LN) J stated that the temperature should be checked daily, but he did not know why the logs were not updated. On 01/18/23 at 11:00AM an inspection of the facility's second floor medication room (200-223 hallway) revealed an incomplete temperature log from January 2023. The only documented date the refrigerator was checked was 01/18/23. [...]

Inspectors wroteThe facility identified a census of 106 residents. The facility identified one resident positive with Carbapenem-resistant Acinetobacter baumannii (CRAB - highly contagious, drug resistant bacterial infection) on isolation precautions. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to transporting clean laundry. The facility additionally failed to store clean linens and hygiene supplies in a sanitary manner. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 01/18/23 at 07:45AM an initial walk-through of the facility was completed. A drawer containing incontinent briefs and bed pads was left open with an opened package of incontinent briefs out on top of the drawer on the second-floor hallway outside of R32's room. [...]

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents. Based on observations, record review, and interviews, the facility failed to ensure adequate equipment was available and used during wheelchair locomotion for Resident (R) 7 and R30. This deficient practice had the risk for accidents and physical complications for affected residents.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with three residents reviewed for beneficiary notices review. Based on observation, record review, and interviews, the facility failed to provide Resident (R)309 with an Advanced Beneficiary Notice of Non-coverage (ABN-form 10055). This deficient practice placed R309 at risk for delay in care or missed services. Findings Included: - Review of R309's EMR indicated that her last covered day (LCD) for Medicare Part A services was 08/24/22. R309 was discharged from the facility on 12/08/22. On 01/18/23 a review of R309 beneficiary notifications revealed the facility or provider initiated her discharge from Medicare Part A services when she had benefit days remaining. The review indicated that an ABN form 10055 was not completed and provided to her upon discharge from the services. [...]

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to notify the state ombudsman of transfers and failed to provide a written notification of transfers with the required information to Resident (R) 20 and or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R20.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold policy to Resident (R) 20 and R42 or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R20 and R42.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with four residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to provide consistent bathing for Resident (R) 2. This deficient practice had the risk for poor hygiene and decreased self-esteem and dignity for R2.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents. Based on observation, record review and interview, the facility failed to follow physician ordered daily weights for Resident (R) 81 who required the use of a diuretic (a medication used for the formation and secretion of urine and reduce excess fluids). This deficient practice placed R81 at risk for excess fluid accumulation and physical complications.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interviews, the facility failed to follow wound care as ordered by Consultant GG for Resident (R) 58. This deficient practice had the risk for delayed wound healing and physical complications for R58.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with two residents sampled for positioning and limited range of motion (ROM) of extremities. Based on observations, record reviews, and interviews, the facility failed to ensure restorative care (care provided to maintain a person's highest level of physical, mental, and psychosocial function in order to prevent declines that impact quality of life) was performed for Resident (R) 31. This deficient practice had the risk for a decline in functional mobility for R31.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with six residents reviewed for accidents. Based on observations, record review, and interviews, the facility failed to implement fall prevention interventions after falls for Resident (R) 16 and R22, and failed to investigate to determine the root cause and implement an intervention for R54's non-injury fall. This deficient practice placed the affected residents at risk for injuries and accidents.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with two residents sampled for bowel and bladder review. Based on observations, record review, and interviews, the facility failed to provide a resident-centered toileting program for Resident (R) 42. This deficient practice had the risk for increased incontinence (lack of voluntary control over urination and defecation), skin breakdown, loss of dignity, and physical complications for R42.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with three reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to offer and monitor intake of nutritional supplements for Resident (R) 54, who was at risk for weight loss. This placed the resident at further risk for unintended weight loss and malnutrition. Findingls included: - R54's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, difficulty in walking, and dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R54 required extensive assistance of one staff member for activities of daily living (ADLs). [...]

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with one resident sampled for dialysis (procedure where impurities or wastes were removed from the blood) review. Based on observations, record review, and interviews, the facility failed to consistently complete dialysis communication sheets before and/or after dialysis which included vital signs and assessments for Resident (R) 31. This deficient practice had the risk for adverse outcomes and unwarranted physical complications for R31.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents. Based on record review and interviews, the facility failed to ensure nursing staff possessed the knowledge and skills to assess neurological status (an evaluation of a person's neurological system to identify signs of disorders affecting the brain, spinal cord, and nerves) for Resident (R) 259 after she had an unwitnessed fall with head injury. This deficient practice placed R259 at risk for fall related complications and further injuries.

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide consistent dementia related assistance related to meals, wandering, and staff interactions with Resident (R)12. This deficient practice placed R12 at risk for impaired ability to achieve and/or maintain her highest practicable level of physical and emotional wellbeing. Findings Included: [...]

Inspectors wroteThe facility identified a census of 106 residents. The sample included 25 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)22 was free from unnecessary psychotropic (affecting mood or thinking) medications when the facility failed to ensure R22's as needed (PRN) lorazepam (psychotropic antianxiety medication) had the required stop date of 14 days. This placed R22 at risk for unnecessary medications and side effects associated with lorazepam use.